Healthcare: The Way It Should BeThe New Era of Opportunity

Healthcare: The Way It Should Be
Section One – Forces Driving Transformation
Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare
Chapter Two – Present and Future Challenges Facing U.S. Healthcare
Section Two – Laying the Foundation for Improvement and Sustainable Change
What will it take to successfully ride the transformational wave?
Section Three – Looking into the Future
What will it take to successfully ride the transformational wave?

Some Pertinent History
For much of history, if you were ill or injured and saw a physician, your chances of survival actually went down.
Hospitals were where people went to die .
“If a physician make a large incision with the operating knife and cure it,… he shall receive ten shekels in money.
If a physician make a large incision with the operating knife, and kill him,…his hands shall be cut off.”
Code of Hammurabi, 1780 BC, Law 215 (of 280)

Leadership is a Verb or Process, Not a Noun…
Between ~1860 and 1915, a few visionary clinical leaders changed all that...
New high standards for clinical education
Strict requirements for professional licensing
Clinical practice founded on scientific research
New internal organization for hospitals
Creation of new, more modern nurse practices
Implementation of more modern hygiene techniques
New public health policies and treatments
Sir William Osler
Florence Nightingale

1912: The ‘Great Divide’
“…for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefiting from the encounter.”
– Harvard Professor Lawrence Henderson, MD
Harris, Richard. A Sacred Trust. New York, NY, New American Library. 1966

Current Health Care…
…is the best the world has ever seen...
Some examples:
From 1900 to 2010, average life expectancy at birth increased from only 49 years to almost 80 years
Since 1960, age-adjusted mortality from heart disease (the #1 cause of death) has decreased by 56 percent
Since 1950, age-adjusted mortality from stroke has decreased by 70 percent

Some Important Points
Most American hospitals and caregivers provide safe and effective care for the vast majority of patients, the vast majority of the time
The vast majority of caregivers are well trained and conscientious
Western medicine’s ability to save and extend life, and to improve the quality of life for the ill and injured is nothing short of miraculous

Does This History Matter?
All of this history is important, because it changes how we think about the present and the future.
As health care increasingly contributes to the national debate, let’s debate in the context of the phenomenal progress we’ve made and the progress we’re capable of making.
The day we engage the hearts and minds of clinicians will be the day that the issues facing healthcare are solved.

How This Impacts the Policy Debate
It is widely accepted that clinicians help patients
Yet, clinicians have little or no control over 90 percent of factors that determine health
Thus, it is unlikely more money for clinical care will advance health
Policymakers believe we are spending enough on healthcare delivery

Healthcare an Expected Benefit?
Since World War II, healthcare coverage has been an expected benefit for the employed…
…and since the late 1960s, an expected benefit for the elderly…
…but will it remain so?

Health Insurance as an Employee Benefit… …Will It Continue?
Probably not…
…data from December 2013 shows that less than 51% of employers now offer health insurance as a benefit…
…and the trend is down…

The Reality…
We are spending more than we can afford on clinical care…
…we have promised more than we can deliver…
…we are not spending as much as we need on major determinants of health…
…something has to change…

A Twofold Solution
The solution to this national dilemma is twofold:
First, we need to slow the rate of growth in spending on health care; and
Second, we have to spend what we devote to health care more effectively (i.e., generate more value)
…clinician-driven, data-driven quality improvement is the answer…

High Touch: Caring, not just curing
“A man stricken with disease today is assaulted by the same fears and finds himself searching for the same helping hand as his ancestors did five or ten thousand years ago. He has been told about the clever tools of modern medicine and somewhat vaguely, he expects that by-and-by he will profit from them, but in his hour of trial his desperate want is for someone who is personally committed to him, who has taken up his cause, and who is willing to go to the trouble for him.”
Szilagyl DE. In defense of the art of medicine. Archives of Surgery 1965; 91:925-30

What do we get for all that money?
High touch – patients value their relationship with a trusted clinical advisor more than any other element in healthcare delivery (the clinician-patient relationship)
Choice – Americans have grown used to maximal choice, to being insulated from the costs of care.
It is unlikely this will continue for everyone; at a minimum, American society will need to define the limits.
Rapid response – the Rule of Rescue

The Rule of Rescue
“The imperative people feel to rescue identifiable individuals facing suffering or death”
– A.R. Jonsen
Subconscious personal identification at an emotional level
A person instead of just a number; a name and a face
The child down the well
The miners trapped in the mine
The whales trapped in ice
The dog on the abandoned boat
Jonsen AR. Bentham in a box: Technology assessment and health care allocation. Law Med Health Care. 1986;14(3-4):172–174

System Performance, by nation
Organization for Economic Cooperation and Development (OECD) data available at: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/04/08/index.html?itemId=/content/chapter/health_glance-2011-36-en

System Performance, by nation
Organization for Economic Cooperation and Development (OECD) data available at: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/04/08/index.html?itemId=/content/chapter/health_glance-2011-36-en

System Performance, by nation
Organization for Economic Cooperation and Development (OECD) data available at: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/04/08/index.html?itemId=/content/chapter/health_glance-2011-36-en

System Performance, by nation
FRA
GER*
UK
US
FRA
GER*
UK
US
U.S. Men and Women Under Age 65 Have Higher Rates of Potentially Preventable Deaths
Slowest Rate of Improvement, 1999-2007
*Data from Germany are 1999 and 2006
Source: Nolte E and McKee CM. In Amenable Mortality—Deaths Avoidable Through Health Care—Progress in the US Lags That of Three European Countries. Health Affairs, published online August 29, 2012.

In Summary…
Over the past century, remarkable progress was made
We need more focus on other determinants of health
Cultural norms—high touch, the desire for choice, and the Rule of Rescue—will likely continue to play a significant role in patient decisions
The pressure to achieve more value from the resources applied to clinical care will grow
Solving healthcare’s issues will be similar to other industries—engaging front line worker in data-driven quality improvement and new, more efficient care delivery models

Healthcare: The Way It Should Be
Section One – Forces Driving Transformation
Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare
Chapter Two – Present and Future Challenges Facing U.S. Healthcare
Section Two – Laying the Foundation for Improvement and Sustainable Change
What will it take to successfully ride the transformational wave?
Section Three – Looking into the Future
What will it take to successfully ride the transformational wave?

Poll Questions…
Is your organization considering new care models like the NCQA Medical Home
Yes
No
Don’t know
33
How difficult will it be for Americans to balance high touch, the need for choice, and the Rule of Rescue to control healthcare costs?
Very difficult
Difficult
Easy
Does your organization have an effective strategy to engage clinicians in data-driven improvement?
Yes
No
Don’t know